Assessing the Relationship between Physical Health, Mental Health and Students’ Success among Universities in Lebanon: A Cross-Sectional Study

Background: Achieving high academic success is known to be influenced by many factors including, but not limiting to, physical and mental health. The present study aimed to assess the relationship between physical health, mental health, and university students’ success, and to explore the associations between these factors and their academic achievement. Methods: A cross-sectional, self-administered online survey was used to collect data from college students in three different universities in Lebanon during the Fall 2023 semester. Mental health was evaluated using validated screening tools for depression, anxiety, and stress, specifically the Patient Health Questionnaire (PHQ-9), the General Anxiety Disorder (GAD-7), and Cohen’s Perceived Stress Scale (PSS), respectively. Additionally, general questions regarding physical health and lifestyle factors were incorporated into the questionnaire. Academic achievement was measured using students’ grade point average (GPA). Results: A total of 261 students completed the self-administered online survey. The results revealed that approximately 42% and 36% of students were experiencing moderate to severe symptoms of depression and anxiety, respectively, and 75.1% of students exhibited symptoms of moderate stress. The majority of participants (99.2%) did not report any physical disability. Chi-square analysis revealed a significant association between mental health status (depression, anxiety, and stress) and GPA level (p = 0.03, p = 0.044, p = 0.015, respectively). Multiple logistic regression models identified eight correlates of GPA and highlighted the relationship between physical health and student success. For instance, students who considered themselves moderately active had lower odds of achieving a higher GPA than those who considered themselves active (OR = 0.41, p = 0.045). Conclusions: This is the first investigation into Lebanese university students’ academic success in relation to lifestyle and mental health profiles. The findings indicate that implementing public health programs and interventions targeting mental health and lifestyle behaviors is essential for enhancing student success.


Introduction
University students play a crucial role in advancing knowledge and fostering progress in society.As future professionals, researchers, leaders, and policymakers, they hold the potential to positively impact the world [1].Academic achievement, a concept that is essential to students' future success, is defined as the degree to which students meet their academic objectives [2].Unlike many similar studies, which mainly used subjective measures of academic performance, in our study, academic achievement was measured by GPA [3], which enhances the reliability of our findings.It is notable that students vary in their academic performance due to several factors, considering the numerous challenges faced by college students [4].Addressing these factors could contribute to enhancing students' success.
Poor mental health among college students is becoming an increasing concern for public health and policy [5,6].The rise in mental illness, particularly among university students, emphasizes the need to comprehend risk factors and potential solutions for an environment that supports mental health.Depression, a major mental health problem, has a remarkable impact on students' ability to perform life activities [7].Therefore, it is necessary to explore the association between mental health and students' productivity, academic performance, and success.Additionally, university students deal with unstable living conditions and make adaptations to changes in their environment, diet, and lifestyle [8].A common phenomenon among college students is weight gain during their initial years.For example, Kasparek et al.'s study revealed an average weight gain of 1.3-3.1 kg among freshmen during their first term at university [9].These unhealthy eating habits and sedentary lifestyle choices may have adverse effects on health in adulthood [10].Moreover, many students deal with various physical illnesses, including chronic diseases and poor nutrition [11].This emphasizes the significance of prioritizing physical well-being among university students and recognizing its association with academic success.
Lebanon, a small middle-income country in the Middle East and North Africa (MENA) region, is struggling with a significant crisis, particularly in the aftermath of the economic meltdown in 2019, the COVID-19 pandemic, and the Beirut Port explosion in 2020.It is also essential to consider Lebanon's distinct socio-cultural background, which is distinguished by its diverse population, encompassing various cultures and religious affiliations [12].These crises, coupled with the country's chaotic history, have had a profound impact on the mental health and overall well-being of the population [13], as well as on the education and lifestyle of university students [14,15].The study findings would be relevant for neighboring countries facing similar challenges.A 2022 study on a sample of university students in Lebanon revealed alarming statistics, with 22.6% and 34.4% of students exhibiting severe symptoms of depression and anxiety, respectively [16].Another study by Fawaz et al. showed that 17.9% of Lebanese students experienced mild depression, 13.8% moderate depression, and 1.7% severe depression.Additionally, 21.9% of students reported moderate anxiety, 6.3% severe anxiety, and 2.3% extreme anxiety [17].Among pharmacy students in Lebanon, a separate study found that 41.8% experienced severe or extremely severe anxiety, 30.7% reported depression, 28.5% faced stress, 27.7% dealt with moderate/severe insomnia, and 45.5% exhibited symptoms of PTSD [18].
To date, only one study has explored the association between health behaviors, mental health, and academic achievement [19].However, academic success was measured using the Subjective Academic Achievement Scale (SAAS).The findings indicated a significant association between a higher frequency of dining out and increased psychological distress with lower SAAS scores.To our knowledge, there is a gap in research regarding the correlation between mental and physical health and GPA among college students in Lebanon, as no previous studies have examined this.Thus, the present study aims to address this research gap in Lebanon.This approach will provide a more objective assessment of students' performance.The key objective of this study is to assess the relationship between physical health, mental health, and university students' success, and to explore the associations between sociodemographic factors and academic achievement.

Study Design and Sampling
A cross-sectional study consisting of a random sampling procedure was conducted during the Fall semester of 2023 (October-December), involving students from three different universities across Lebanon.These universities included two renowned private institutions, the American University of Beirut (AUB) and the University of Balamand (UOB), as well as the Lebanese University, which is the sole public university with multiple branches and majors throughout the country.Based on a similar study conducted by Baert et al. [20], the required sample size was determined to be 220, with a 95% confidence interval and a precision level of 40%.To accommodate an additional 20% refusal rate, a total of 264 college students were included in this study.The sample size was stratified according to university size and gender, resulting in the need for a total of 137 women and 127 men for this study.

Data Collection
After obtaining approval from the Dean of the Student Affairs Office at the respective universities (to avoid any undue influence or coercion), the research team visited the universities included in the study.They randomly approached students and invited them to participate in a self-administered online questionnaire.Upon agreeing to take part in the study and reviewing the consent form (Supplementary File S1), participants proceeded to complete the survey (Supplementary File S2).The survey's completion took approximately 10 min.
Participation in the survey was entirely optional and anonymous.Additionally, participants were encouraged to ask questions related to the study or seek additional clarification before consenting to participate.Moreover, the study received approval from the Institutional Review Board (IRB) at AUB, and the research team was Collaborative Institutional Training Initiative (CITI)-certified.

Survey Format
The survey aimed to assess the mental and physical health of university students, along with factors associated with student success.According to the Cambridge University Reporter, examination performance is commonly used to assess academic performance [21].In this study, academic achievement was measured by GPA, reflecting students' performance in assignments, tests, and exams.A higher score indicates better academic performance [2].The questionnaire was created based on similar studies in the literature [16,22] and comprised four sections.The first section consisted of questions about participants' sociodemographic characteristics and university-related factors, including age, gender, area of residency, educational level, and major.
The third section focused on the participants' physical health (for instance, BMI) and lifestyle factors (for instance, physical activity, sleeping habits, and diet), whereas the last section included questions on students' success.The questionnaire was pilot tested on 10 students to check for clarity.Data collected during the pilot testing phase were not incorporated into the present study.Supplementary File S2 contains a copy of the questionnaire used for data collection.

Statistical Analysis
Data were rigorously checked for completeness and were then entered into the Statistical Package for the Social Sciences (SPSS) version 29.0 (SPSS Inc., Chicago, IL, USA) for data analysis.Descriptive statistics were used, such as counts and percentages, for the categorical variables and means and standard deviations (SD) for the continuous ones.Chi-square (χ2) was used to calculate the association between two categorical variables.Note that GPA for UOB students was multiplied by 0.98, whereas for LU students, it was multiplied by 1.2 in accordance with AUB equivalence system.GPA was then dichotomized.The mean GPA score was considered the cut-point.Participants reporting a GPA below the mean score, i.e., between 0 and 79, were considered to have a low to moderate GPA, and those reporting a GPA above or equal to the mean score, i.e., 80 and above, were considered to have a high GPA.
Simple and multiple logistic regression were applied to investigate which factors were associated with student success, using the GPA score as an dependent variable and the sociodemographic factors, such as mental and physical health and university, as independent variables.All variables that were found to be significant in the simple analysis were added simultaneously to the multiple regression models as independent variables.Results from the logistic regression analyses were expressed as odds ratios (ORs) with their respective 95% confidence intervals (CIs).A p-value below 0.05 was considered statistically significant in all analyses.

Sociodemographic Characteristics
A total of 264 students completed the online survey, with 261 providing complete data and being included in the final analysis (resulting in a 99% completion rate).The sociodemographic characteristics of the study population, along with some information about their studies, are presented in Table 1.Based on the gender and university stratification plan, approximately 52% of the students were women, with 27.6% enrolled in AUB, 51.3% in LU, and 21.1% in UOB.The average age of the college students was 20.29 years (SD = 2.025), ranging between 17 and 33 years old.The majority of students were from Beirut (40.2%) and Mount Lebanon (31%).A significant portion of the participants were Lebanese (92.3%), and many were enrolled in non-health-related majors (73.6%).About 64.4% of the participants lived with their families.Additionally, around 36% of the students reported a personal monthly income between USD 100 and 300.Nearly half of the participants' parents held a university degree.Most students had working fathers (92.3%), while 56.7% had working mothers.Moreover, more than two-thirds of the participants had no employment (72.4%) and did not receive any financial aid or scholarship (67%).Approximately 32% reported studying more than 30 hours per week.Finally, 48.7% of college students had a low to moderate GPA, while 51.3% had a high GPA.

Mental Health of Participants and Its Association with GPA
Among the study sample (Table 2), 73.5% of students exhibited mild to moderately severe symptoms of depression, and 80.5% displayed mild to severe symptoms of anxiety.Specifically, 44.1% showed mild symptoms of anxiety, while 10.7% exhibited severe symptoms.Approximately 75.1% presented with moderate symptoms of stress, and 13.4% of students exhibited high perceived stress.More than half of the participants (64.7%) believed that their mental health had a negative impact on their ability to learn, focus, and perform well in university.
Estimates shown in bold are those that are statistically significant at p < 0.05.
As indicated in Table 2, significant differences were observed in the mental health status (depression, anxiety, and stress) of college students based on their GPA level.The rating of the negative impact of mental health was also significantly associated with GPA level.

Physical Health of Participants and Its Association with GPA
As shown in Table 3, the majority of college students in the study sample did not report any physical disability (99.2%) or chronic disease (83.1%).Among those who reported chronic disease, asthma was the most prevalent (38.6%).About 52.1% of participants experienced frequent headaches, fatigue, or stomachaches.Only 36.4% considered themselves physically active, while 45.6% reported being moderately active, and 18% described themselves as sedentary.Moreover, 47.9% of students went to the gym, 38.3% were daily smokers, and 33.3% consumed alcohol, with 24.5% doing so less than two times per week.Approximately 14.2% of participants identified as underweight, while 11.5% considered themselves obese.More than half of the participants (59.4%) were satisfied with their weight, and 52.5% reported weight fluctuations during their university years.Additionally, 65.9% of students reported having regular sleeping habits, and 57.5% believed they followed healthy eating habits, with homemade food being the most preferred option (42.5%).Only 32.9% of participants believed that their physical health negatively impacted their ability to learn, focus, and perform well in university.Finally, GPA was significantly associated with physical activity, smoking habits, gym attendance, and weight satisfaction.Estimates shown in bold are those that are statistically significant at p < 0.05.

University Factors and Their Association with GPA
As shown in Table 4, a significant portion of the participants (79.3%) never thought of dropping out of university.More than half of them (59.4%)believed they would complete their studies on time.Approximately 40% engaged in internships or other opportunities to gain practical experience in their fields and actively participated in extracurricular activities (ECAs).Furthermore, 66.7% of students expressed satisfaction with the quality of education and the learning environment provided by their institution, while 54.8% were pleased with the quality of services offered by the student affairs office at their institution.Finally, the results revealed a significant association between GPA and the likelihood of finishing studies on time, as well as satisfaction with the quality of education provided by the institution.Estimates shown in bold are those that are statistically significant at p < 0.05.

Simple and Multiple Logistic Regression Analyses
Simple logistic regression analysis revealed that fifteen predictors were significantly associated with participants' GPA level (Table 5).These predictors included the area of residency (OR = 0.396, p = 0.002), where participants from Mount Lebanon were less likely to have a better GPA than those residing in Beirut.Other significant predictors comprised the stage of study (OR = 2.718, p = 0.036), major (OR = 1.836, p = 0.035), mother's employment status (OR = 3.904, p = 0.01), university enrollment (OR = 0.377, p = 0.009), PHQ9 (mild depression: OR = 0.448, p = 0.025; moderately severe depression: OR = 0.26, p = 0.002), GAD7 (OR = 0.338, p = 0.005), PSS (OR = 0.35, p = 0.045), negative impact of mental health (a great deal: OR = 2.271, p = 0.01; some: OR = 2.667, p = 0.004), physical activity (moderately active: OR = 0.501, p = 0.014; sedentary: OR = 0.396, p = 0.011), gym (OR = 0.479, p = 0.004), smoking (OR = 1.968, p = 0.009), weight satisfaction (OR = 0.584, p = 0.034), finishing study on time (OR = 0.47, p = 0.024), and satisfaction with the quality of education provided by the university (OR = 0.547, p = 0.023).The results from the multiple logistic analysis revealed several significant associations with participants' GPA levels.More specifically, participants with a health-related major were more likely to have a high GPA compared to those with a non-health major (OR = 3.874, p = 0.007).Students studying at UOB had lower odds of having a high GPA compared to those studying at AUB (OR = 0.222, p = 0.004).Additionally, participants who reported being moderately active were less likely to have a high GPA compared to those who reported being active (OR = 0.41, p = 0.045).Students who do not smoke daily were more likely to have a high GPA compared to those who smoke daily (OR = 2.948, p = 0.003).Further, participants who reported being unsatisfied with the quality of education and the learning environment provided by their institution were less likely to have a high GPA compared to those who reported being satisfied (OR = 0.439, p = 0.033).Also, students who have working mothers specifically self-employed were more likely to have a high GPA compared to those who have non-working mothers (OR = 3.971, p = 0.043).Finally, the results showed that the student's area of residency, and whether they consider that mental health has a negative impact on their studies were all significantly associated with their GPA level (OR = 0.363, p = 0.011; OR = 3.019, p = 0.038, respectively).

General Findings
The present study is among the few conducted in the MENA region, including Lebanon, that investigates the correlations between mental health, physical health, and academic achievement.To the best of our knowledge, this is the first study in Lebanon to employ GPA as a measure of students' success, departing from more subjective methods such as the Subjective Academic Achievement Scale (SAAS) [19].
Our results revealed alarming rates of depression and anxiety, surpassing those documented in previous studies.Specifically, our findings indicated that nearly 76% of students exhibited mild to moderately severe symptoms of depression, and approximately 70% reported mild to moderate symptoms of anxiety.In contrast, studies conducted in 2018 showed that 56% of students were experiencing mild to moderate depression symptoms, with 36% and 34% presenting combined symptoms of depression and anxiety, respectively [26,27].Despite using identical mental health indicators, these variations may be attributed to methodological differences, particularly the focus on single universities in the latter studies.The ongoing crisis in the country could be another influencing factor contributing to the increased prevalence of mental health issues among young adults, especially since the previous studies were conducted before the economic crisis and the onset of the COVID-19 pandemic.Furthermore, the levels of anxiety reported in our study were higher than those documented among college students in Lebanon in 2021 (50%) [16], the United States (15.9%) [26], and Canada (32.6%) [28].Additionally, approximately 75% of our study sample exhibited moderate stress levels, a figure higher than the reported levels among pharmacy students in Lebanon (27.7%) [18].
The present study also revealed that a significant percentage of students reported a negative impact of their mental health on academic performance.This finding is consistent with a Student Voice survey on health and wellness conducted by Inside Higher Ed and College Pulse, where half of the students asserted that their well-being adversely affects their academic progress [29].In a longitudinal study conducted in the United States, it was found that mental health problems predicted delayed academic success (GPA) [30].It is worth noting that mental health issues and their relationship with students' success have not received sufficient attention in the MENA region compared to other countries [31].The present study's findings highlight a significant association between mental health and student success.These findings highlight the urgent need for comprehensive mental health support services on university campuses to address the well-being of students and mitigate the adverse effects on their academic success.
Our findings indicate that only 11.5% of students perceive themselves as overweight or obese, a considerably lower proportion compared to other studies.For example, a cross-sectional study encompassing university students from 22 low-, middle-income, and emerging economy countries reported that 22% of participants were overweight or obese [32].Similarly, a study conducted in Egypt found that approximately one quarter of males and one third of females fell into the overweight/obese category [31].A potential explanation for our results may be attributed to self-reported bias, as students were required to assess their weight based on BMI.Additionally, the mean BMI of college students in our study sample was 22.41 ± 3.37, aligning with acceptable ranges observed in previous studies conducted in Lebanon, Morocco, and Saudi Arabia [19,[33][34][35].Although our study did not identify any association between BMI and GPA, it is noteworthy that several studies have indicated a negative relationship between BMI and academic achievement [36,37].Future studies should examine the complex relationship between academic achievement and weight status, accounting for variables like health behaviors and body image perception.
Our results indicated an association between GPA and the area of residency, contrary to findings in other studies.For instance, Alfifi et al. discovered that the residential area has no significant influence on academic achievement [38][39][40].In contrast, their research found that women outperformed male students, while our findings revealed no gender-based differences in GPA among college students in the study sample.Additionally, in line with previous studies, our results demonstrated that students pursuing health-related majors were more likely to achieve higher GPAs compared to non-health majors [39,40].This differs from a study conducted in Lebanon, where better academic achievement was observed among students with non-scientific majors, potentially influenced by the subjective method used to measure academic achievement in that region [19].It follows from previous research that parents' socio-economic status, including academic and professional qualifications and income, can be associated with student success [22].However, in the present study, only the mother's employment status was found to be significantly associated with GPA.The university in which students were enrolled was also identified as a factor affecting GPA, possibly attributed to varying resources and facilities offered by each institution.This finding aligns with the significant association observed between students' satisfaction with the quality of education provided by their institution and GPA.Regarding physical and lifestyle factors, a significant association was revealed between smoking and GPA, consistent with lower GPAs among students who smoke, as reported in previous studies [19,41].Physical activity also showed an association with GPA, with sedentary students being less likely to achieve high GPAs compared to their active counterparts.This association was previously highlighted in a study among medical students in Saudi Arabia [42].
Sleep deprivation is common among university students and has been linked to poor academic performance [43].While a study in Belgium found a positive relationship between sleep quality and academic achievement [20], no association was found between sleeping habits or hours and GPA in our study.

Scientfic and Practical Recommendations
The results of our study have consequences not just for Lebanon but also for other nearby countries in the MENA region, where problems with university students' mental, physical, and academic well-being may be common.The MENA region shares certain issues including economic instability, political turmoil, and the effects of global health crises [44].Thus, the knowledge gathered from our research could guide the development of interventions and policies meant to promote the academic achievement and general well-being of university students in surrounding countries.
Moreover, our research highlights the necessity of paying more attention to mental health concerns among college students worldwide.The concerning rates of stress, anxiety, and depression that our research revealed are likely not specific to Lebanon; rather, they could be a reflection of larger patterns that influence young adults across a range of cultural contexts [45].Because of this, international efforts to address mental health on college campuses should be prioritized, with an emphasis on developing supportive learning environments, facilitating access to mental health services.

Research Limitations
The findings of the current study should be interpreted considering the study's limitations.First, our study was cross-sectional; causal relationships cannot be drawn.For instance, students from low-income families may face unique challenges such as limited access to opportunities for physical activities, which could affect their academic performance.Moreover, time constraints may be associated with students' ability to dedicate sufficient time to learning.Therefore, future studies using longitudinal designs could be developed to better understand causal relationships.Second, the data collection process utilized self-reported responses to assess the relationship between both physical and mental health factors and the academic success of university students.However, it is important to acknowledge the potential for inaccuracies stemming from memory recall or social desirability bias within these responses.Third, this study primarily employed quantitative methods for assessment.Future research endeavors may benefit from incorporating qualitative approaches to further explore the relationship between physical health, mental health, and university students' success, thereby offering a more comprehensive understanding of the subject matter.

Conclusions
The present study shed light on the alarming levels of depression, anxiety, and stress reported among college students.Our findings highlighted the association between mental and physical health with GPA, emphasizing the critical need for targeted interventions to support student well-being and academic success.Policymakers and universities must develop and implement awareness campaigns and health education initiatives tailored specifically to the needs of university students.In order to reduce the negative impact of mental health issues on academic performance, these programs should emphasize the promotion of a healthy lifestyle, which includes regular physical activity, a balanced diet, and enough sleep.Furthermore, it is critical to create a welcoming campus environment that promotes open dialogue about mental health and easily accessible options for students in need of support.

Table 1 .
Sociodemographic characteristics and university factors of college students in Lebanon in the study sample (n = 261).
a Sociodemographic characteristics, b university factors, 1 GPA: grade point average; 2 BMI: body mass index.Estimates shown in bold are those that are statistically significant at p < 0.05.

Table 5 .
Simple and multiple logistic regression.